Shortly after his inauguration, President Donald Trump took a set of thick, black permanent markers and signed a sweeping set of executive orders that took aim at everything from immigration and gender to TikTok and climate change. One of his first moves was to withdraw the US from the World Health Organization (WHO), the United Nations’ global health agency responsible for safeguarding and promoting health around the world since 1948.

The US is one of the WHO’s biggest funders, so any shortage of financial and political support will likely have major ramifications for global health efforts like eliminating malaria, improving access to high-quality health care, and reducing maternal mortality. While that may not directly matter to rich countries like the US that have the means to address their own health challenges, one of the WHO’s most important jobs is to help coordinate the international response to pandemics and outbreaks — events that can threaten everyone, regardless of borders, as we learned during Covid-19.

To Trump and his supporters, the WHO’s perceived failure on that job is one of the biggest reasons why the US should withdraw. Chief among Trump’s complaints are the WHO’s mishandling of the Covid-19 pandemic and other global health crises, its failure to reform, and its inability to demonstrate independence from powerful but authoritarian WHO member states, namely China.

Trump’s decision has engendered plenty of criticism, including from experts who argue that the US could suffer if it loses access to vital WHO data on outbreaks. Still, the WHO is far from perfect, and even before Trump, scientists, think tanks, and government bodies have been pointing out the WHO’s myriad problems, from the lack of term limits for senior leadership to its massive budget for headquarters staff who are paid additional stipends (around $5,000 to $7,000 per month) to cover the cost of living in Geneva, one of the world’s most expensive cities.

I’ve seen the inefficiencies and mismanagement first hand: In my almost 10-year career as a global health epidemiologist, I have interacted with the WHO on many occasions, including, at times, coordinating with them to respond to disease outbreaks in Africa. Like Trump, my biggest complaint is that the organization has shown it is loath to reflect on and address its deficiencies — deficiencies that matter hugely when it has been given the monumental responsibility of safeguarding the world’s health. There has always been some intangible and unspoken sense that the WHO cannot be wrong and cannot be questioned, even after it was clear that it bungled certain aspects of the Covid-19 pandemic.

But while the WHO is far from perfect, many of its flaws are symptoms of more fundamental challenges that go beyond how it is governed. Balancing the need to respond to international health threats while respecting national sovereignty means cooperation is a fine line — and it’s one that’s becoming harder for the agency to walk.

For the WHO to survive, it needs to improve. And for the US to have the best chances of protecting itself from future global health emergencies — especially as the Trump administration also works to dismantle the United States Agency for International Development, another key player in global health and development — it still needs the WHO. But it needs a better one.

What Trump gets right — and wrong — about WHO

In his executive order, Trump reiterated many of the same issues he raised five years ago when he first threatened to withdraw from the WHO.

One of Trump’s biggest complaints was that the agency was too slow to alert the world of an emerging health threat in China and to move to contain its spread. Local newspapers had been reporting that a mysterious illness was spreading around Wuhan as early as November 17, 2019, a fact backed up by genetic analysis.

But Chinese health authorities didn’t alert the WHO — which the country was required to do under a legal framework called the International Health Regulations — to a spate of patients with an unknown pneumonia-like disease until December 31. By then, valuable time to contain the disease had been lost, though it is Beijing, not WHO, that is largely at fault for this lag.

Still, while the WHO has limited if any power to compel China or any other country to act, the body should have been more proactive in November and December.

“WHO has country offices, WHO has relationships with Ministries of Health. I would argue they certainly should have been aware this was happening,” said Ashish Jha, the dean of Brown University’s School of Public Health and the White House Covid-19 response coordinator during the Biden administration. “It was showing up in a lot of media, social media, and they should have pushed the government to say, what is this? What is going on here, and why don’t we know more about it?”

Within five days of learning about the unusual cases in China, the WHO had alerted its member states. But the WHO’s Director-General Tedros Adhanom Ghebreyesus traveled to China and, instead of confronting the government about its obfuscation, heralded Beijing’s response to the outbreak. And then the WHO consistently parrotted inaccurate information from the Chinese government — namely that the virus was not spreading from person to person — to the rest of the world for weeks.

While the WHO proclaimed Covid-19 a public health emergency in late January, the messaging from the highest levels of WHO in those early months, when officials believed it was still possible that Covid could be contained, was too often confusing.

“For the moment, we are not witnessing sustained and intensive community transmission of this virus, and we are not witnessing large-scale severe disease or death,” Ghebreyesus said during a briefing in late February. That was simply untrue. By that time, China had reported almost 80,000 cases and nearly 3,000 deaths from Covid-19, while 37 other countries were also reporting cases and deaths.

It also took the WHO two years, until late 2021, to finally acknowledge that Covid-19 was airborne, despite the mountain of evidence that scientists had amassed just six months after the first cases. A WHO spokesperson pushed back against this. “From January 2020, WHO said transmission was occurring between people when they breathe, talk (later sing) and especially in settings like hospitals, households and long term living facilities,” a spokesperson told Vox by email. While some of this confusion stemmed from longstanding disagreement on what exactly constitutes airborne spread, as late as March 2020 the WHO was still confidently tweeting, “FACT: #COVID19 is NOT airborne,” even as people were being infected through the air.

Trump has also repeatedly criticized the WHO for not fully investigating the theory that the Covid-19 virus originated from virological work in a laboratory in Wuhan, rather than the conventional explanation that it began in wild animals sold at a meat market. The WHO sent a team of investigators to China in 2021, but Chinese scientists refused to discuss the so-called “lab leak” theory and then pressured investigators to dismiss the possibility altogether, according to the lead scientist on the team.

Again, though, the WHO has no authority to compel member states to turn over data or to cooperate on investigations. In fact, the WHO cannot even work inside a member state without that country’s permission. This is certainly a limitation of the WHO, but that’s because it answers to its member states — it is not some sort of supra-national health policy enforcement body.

Beyond Covid, Trump has also griped that the WHO requires the US to make “unfairly onerous” payments, because US dues exceed the payment the organization demands of China, which has about four times the number of people as in the US.

The WHO is funded in two ways. The first is through assessed contributions, essentially membership dues, that each WHO member state is required to pay each year. The United Nations has a process for determining how much each country owes, but it’s essentially based on a country’s gross domestic product (GDP), not its population size.

US GDP in 2023 was about 1.5 times higher than China’s. That year, the US was required to pay the WHO $218 million, about two times more than China was assessed. So while the US does pay more than China, that difference is almost, though not quite, proportional to GDP.

Assessed contributions, however, make up less than 20 percent of the WHO’s total funds. Its other funding comes from voluntary contributions from member states and non-governmental donors, such as the Bill and Melinda Gates Foundation.

Here is where the US and China make vastly different contributions to the WHO. In 2023, China gave the organization about $40 million in voluntary contributions plus an additional $935,000 toward an emergency fund on top of its assessed contribution, while the US government donated more than $1 billion in voluntary funds and about $47 million toward the emergency fund. In all, that meant the US gave the WHO about $1.27 billion in 2023, about 18 percent of their total budget, while China gave about $156 million when you tally up all contributions. So while the US does give vastly more to the WHO than China, most of that is in voluntary donations.

Of course, the US doesn’t have to pull out of the WHO altogether to rectify this situation — it could simply choose to donate less to the WHO, or mandate that its contributions come with reform. And the institution does need reform.

Who’s at fault at WHO, explained

Covid wasn’t the first time the WHO came under international fire. Take the 2014 Ebola outbreak in West Africa.

The organization was criticized back in 2014 for its long delay in declaring the outbreak a public health emergency, which hindered swift containment measures that could have prevented the virus from spreading across borders. From the start, the WHO fundamentally underestimated the severity of the outbreak — Ebola would go on to kill more than 11,000 people primarily in Guinea, Liberia, and Sierra Leone, with scattered cases reported in the US and several European countries, too. It ultimately took the WHO and its partners two years to get the Ebola outbreak under control.

Despite the number of deaths, Ebola’s spread was limited largely because it isn’t a respiratory disease like Covid-19; rather it spreads through direct contact with an infected person’s bodily fluids. But that fact makes the failure to contain Ebola all the more glaring.

To be fair, all outbreak and pandemic responses are chaotic, especially when an entirely novel virus like Covid starts spreading. New information is constantly emerging, and a lot of different individuals and institutions have to come together to coordinate the flow of information and the rollout of interventions or recommendations, even as the full picture of the outbreak is inevitably unclear. Outbreaks often happen in far-flung areas that lack health care workers, hospitals, laboratories, and even roads and internet. Cultural practices, economic conditions, and a preexisting lack of trust in politicians and health officials further complicate responses.

The WHO also came under fire for delaying the dissemination of vaccines to help curb an ongoing mpox outbreak which began in May 2022 and spread to more than 120 countries before the virus became largely confined to central and eastern Africa.

In mid-2022, the US and EU approved an mpox vaccine made by the Danish pharmaceutical company Bavarian Nordic. But the WHO, which has its own process for reviewing and approving drugs and vaccines, did not approve the vaccine until September 2024.

That delay mattered. For one, other organizations like UNICEF and Gavi that play a critical role in procuring and distributing vaccines in developing countries require WHO approval before they can move forward with vaccination campaigns. Many developing countries do not have or have only pared-down versions of drug regulatory agencies so they also rely on the WHO to approve medicines before they roll them out in their countries, explained Rogério Gaspar, the director of WHO’s Department of Regulation and Prequalification. And so when it came to the mpox vaccine, many countries — especially in Africa, where the outbreak was most severe — were waiting for the green light from WHO before they could roll out the needed vaccines, even though the US and Europe had already approved them.

The WHO blames the long delay on Bavarian Nordic. The WHO claimed that the company did not submit the mpox vaccine for review until August 2024, some two years after the mpox outbreak had begun, and that once it did, the WHO approved it within two weeks, according to a WHO spokesperson.

But Bavarian Nordic refutes this timeline. A spokesperson told Vox that the pharmaceutical company first met with WHO in August 2022 and submitted a dossier on the vaccine in May 2023. The dossier they submitted to the WHO contained the same information that led to the European Medicines Agency, the equivalent of the FDA, approving the vaccine for use in Europe. It isn’t clear why the WHO didn’t act sooner. Back in August 2024, the WHO director of health product policy and standards, Deusdedit Mubangizi, told reporters that there wasn’t enough data to support its approval. But now, it seems, the WHO has changed its story, ducking accountability once again.

The entire process has frustrated some public health experts. “It’s almost like WHO saying, hey, we’re not responsible for our own process,” Jha said. “This is the lack of accountability. It’s everybody else’s fault.”

(A WHO spokesperson pointed out that member states did not have to wait until the WHO’s review was complete to buy and distribute the vaccines.)

Over the years, the WHO has tried to address its critics through a laundry list of reform efforts — and there has been some improvement. Between 2020 and 2022, smaller Ebola outbreaks in the Democratic Republic of the Congo, Uganda, and Guinea have been contained in just a few months. That’s a hopeful signal the organization has potentially improved not only its own ability to quickly respond to outbreaks, but has also helped build member states’ capacity to detect and contain health emergencies. It also helps that since 2014, scientists have also developed a number of vaccines and treatments that would certainly help quell an outbreak.

Still, while there were improvements in the Ebola response that can be attributable to the WHO, the organization’s dismal performance during the Covid-19 pandemic suggests that these reforms remain insufficient. And the bigger issue is that the WHO simply cannot admit its mistakes. The organization has still not come out and listed the errors it made during the Covid-19 pandemic. Though the WHO convened an independent panel of experts to review the international response to Covid-19, the panel’s reports largely focus on the failures of WHO member states and say little about the WHO’s own shortcomings.

“There is very little interest at WHO in introspection,” Jha said. “There’s very little interest in WHO in figuring out how to do better.”

And given how enormous — and how difficult — the WHO’s responsibilities are, that introspection is needed.

The WHO’s impossible task

The WHO’s mission is to foster global public health, but what that means in practice depends on what counts as global. As it stands, its 194 member states (193 without the US) have tasked the organization with outbreak prevention and response and other responsibilities that impact nearly all countries. That includes setting international health standards and collecting data on an ever-increasing list of health priorities ranging from maternal and child health and nutrition to sanitation and clean water. But some of the WHO’s work focuses on supplementing national health programs and filling gaps that benefit individual nations — specifically those with the least resources — rather than the world as a whole.

Those responsibilities fit poorly with a Trump administration that is bringing an America First approach to health — and other countries are taking notice. Argentina has announced that it also plans to withdraw from the WHO, while Italian politicians have introduced legislation that would do the same. Other European countries have slashed global health aid budgets in recent years.

That the US cannot remain a WHO member while also consciously putting itself first highlights a friction in the field. Is global health about containing dangerous outbreaks so they don’t breach your own border and pose a threat to national security? Or is global health about saving lives and improving the health of everyone, regardless of their nationality? Can competing nation-states like China and the US set aside their political warfare and come together on one issue — health — or has the time for international cooperation finally ended?

One way to address that contradiction would be for the WHO to scale back on the number of health areas it is involved in and focus primarily on issues that actually transcend borders. This would include infectious diseases — but only those that present a truly global threat.

The WHO itself puts together a list of pathogens with the potential to cause a pandemic. It includes familiar diseases such as West Nile, Zika, Ebola, and Covid-19. Many of these have already caused deadly outbreaks and pandemics. Something else that transcends borders: products such as cigarettes or baby formula. The WHO might also have a role to play in regulating the safety of these products, according to Jesse Bump, a public health professor at the Harvard T.H. Chan School of Public Health.

This recommendation is not to say that newborn and maternal health or access to clean water are not important, life-saving services that everyone on Earth should have. But these represent more national health priorities for the countries dealing with these issues and not truly global threats.

Without some form of additional support, paring down the WHO’s focus areas would have fatal consequences for some places. Particularly in low-income countries, the WHO serves as a lifeline of essential health services and often fills many of the responsibilities that national health agencies in wealthy nations like the US handle, a WHO spokesperson explained.

Of course, the fact that the WHO is tasked with addressing so many different areas of health fundamentally reflects both the massive health disparities around the world and the way the organization is funded. Consider the health challenges that a country like the US faces compared to many developing countries. In places like Niger, Papua New Guinea, Chad, and the DRC, more than half of the population does not have access to clean drinking water or basic water services. More than 50 percent of people in Somalia and Haiti are malnourished. In southern Africa, HIV is still a leading cause of death; in parts of West Africa, malaria is a leading cause of death.

In much of the global north, by contrast, these health challenges are virtually nonexistent, and where they are present, it’s because of national priorities, not a lack of national resources.

Consider as well the drastic difference in the health workforce around the world. In many low- and middle-income counties, there are major shortages of doctors and nurses, not to mention specialists such as neurologists or surgeons. In more than 50 countries, mostly in Africa and the Middle East, there are fewer than one doctor per 1,000 people in the entire country. The US has almost four times as many doctors per capita.

What this means is that the state of health and health care is so grossly unequal across countries that one organization cannot possibly address them all while also ensuring that every member states benefits equally from their WHO membership.

And the benefits are unequal, at least in strict financial terms. Last year, countries in Africa and the WHO’s Eastern Mediterranean region — which includes parts of North Africa and the Middle East including some very poor and conflict-afflicted member states such as Afghanistan, Yemen, Syria, Somalia, and Sudan — received $2.9 billion, almost half of the WHO’s $6.8 billion budget. The region of the Americas, which includes the US, received the least amount of funding, just over $300 million. But even here, it’s important to understand that the inequality in who gives and who gets from the WHO is largely a function of the fact that some regions and countries simply have a massively greater need for international aid.

It’s important to remember that the WHO has limited control over its own agenda. It is member states themselves who vote on the organization’s scope of work and approve its budget. Beyond the required payments, countries and other donors can earmark their voluntary funds for specific causes. The US, for instance, earmarks more than half of its funds for epidemic prevention or response and polio eradication while Nordic countries typically focus their funding on maternal health.

This approach to funding helps the WHO account for individual member state priorities but also allows countries to use funds to influence the WHO’s scope of work. Ultimately, it means that the WHO has little choice but to expand and scatter its workforce to make sure every country’s pet projects get completed.

Is there any room for WHO in America First?

Short of remaking the WHO into an institution under the leadership of the US government, it’s difficult to imagine that any amount of reform will satisfy the current administration. The organization’s mission is completely misaligned with Trump’s “America First” agenda. In the WHO, as in most other UN international bodies, America does not come first. It has the same vote as every other member state, even though the US contributes more money than any other country.

But despite its many shortcomings, the US needs the WHO. Only an international health agency such as the WHO can overcome the nuanced complexities of economic competition, geopolitics, and even outright war, to respond to global health emergencies. The WHO serves as a bridge for sharing information and even biological samples of pathogens, which is critical for understanding how a disease will spread and for developing medicines and vaccines.

Trump’s vision of global health or public health, for that matter, is unclear. Just as unclear is whether Trump’s executive order on the WHO is even legal. Members of Congress have asked Trump to reconsider. Though the full impact of the US withdrawal will probably not be felt for about a year, the WHO’s director-general has already ordered a hiring freeze, mandated that some contracts be renegotiated, and directed staff in country offices to provide only essential support.

As the WHO adapts to a future without US investment, the Trump administration is also gutting other key global health efforts. This month, thousands of USAID staff were laid off, leaving only about 300 employees of a once 10,000-person workforce. It isn’t yet clear what global health areas the drastically smaller agency will work on — or whether it will exist at all — and it wouldn’t be surprising if the administration goes after other global health initiatives like the ones led by the Centers for Disease Control and Prevention.

American retreat from both the WHO and its own broader global health efforts paradoxically makes the case for WHO reform all the more important. Many complaints about how the WHO does its work are valid, especially given its reluctance to confront mistakes. But much of what it is criticized for is built into the way the institution itself operates or reflects a world with hugely varying health problems and national abilities to meet them. Still, the WHO must do better because it is the only organization uniquely placed to bridge diplomatic tensions and address international health threats. The most hopeful read on Trump’s action will shock the bureaucracy into action, and lead the Trump administration to ultimately realize that an American-first approach must include the WHO.